Everything Goes Through Me

On an ordinary day last month, I saw patients for eight and a half hours. I addressed a dozen computer messages, took four or five calls from outside providers and held innumerable curbside conversations with medical assistants, case managers and colleagues.

I didn’t get to any of the 100+ lab results or 50+ documents in my electronic inboxes. Consequently, the care for several dozen of my patients didn’t move forward.

Many of them didn’t get the news that their blood tests, mammograms or CT scans were normal; some never got scheduled for follow up visits to discuss options based on their mildly abnormal studies; a few didn’t get their highly abnormal tests acted on. Others didn’t get their annual eye exams logged in their diabetic flow sheet.

This happened because I am the official bottleneck by virtue of the “work flow” dictated by our electronic medical record.

My last office note might say “Follow up to review results”, but if I am late getting through my inbox, the clerical task of scheduling that appointment doesn’t happen.

It’s a little bit like having me answer our clinic’s telephone, or, a presumptuous analogy, the President opening the Government’s mail and then forwarding each item to the proper cabinet secretary.

Because every piece of data in a medical office has an ordering provider or a provider of record, it seemed like an EMR no-brainer to send everything to that person. But I think someone forgot that the current primary care business model is based on each medical provider cranking out as many visits per day as is humanly possible. That makes desk work a money losing activity.

With all the talk about having everyone in the medical office work to the top of their license, I think it is high time we turn the virtual mail sorting work flow on its head:

Have non-providers check incoming reports and lab test against existing treatment plans with cut-offs for when to interrupt providers, and give the provides more time to provide care and make medical judgements. A lot of information comes in to the primary care office just so we can maintain a record of patients’ care. It isn’t necessarily imperative to have the physician read a seven page specialist report to find one relevant medication change that needs to be updated in a patient’s record. That is what we used to call secretarial work in the old days, but that word and concept, dear Health Care Industry Comrades, seems to be taboo these days.

So, back to my reality: Last night, after cleaning the horse stalls, I spent almost two hours going through my backlog of reports. At least I was able to do my work from home, in the company of my horses, but I keep feeling that on a daily basis I am making up for a system that isn’t all that well designed.

I am a fan of paying doctors for this time. My other issue is that results should be released to the patient. They need to take responsibility to look them up. A patient that is involved with their health, and gets educated in the right places to look, is going to do a lot better than one who doesn’t.

This way time is taken off the doctor, the patient gets what they need/want.

I agree with what you say completely. As one way of doing this, I think a lot of practices have MAs or NPs that take care of this for them. I know there are other practices that have figured out how to get past this bottleneck. I can’t comment on your specifics, but I think if you do some research you will find some ways to get rid of this inefficient use of your time. I hope you do. Everyone suffers as a result of this. It drives up the cost of care and burns out doctors. We don’t need this.

The same thing happens in the hospital. As a Hospitalist I am the official ” team” secretary. I spend my day doing mundane clerical tasks that were previously done by others so I had time to review the medically pertinent materials. It was my job to make sure we had the correct diagnosis or were on the correct diagnostic and therapeutic plan. No time for that anymore. Says patient care RN, “Sorry to interrupt you doctor , but can you change the tylenol from suppository to tabs?” I say “Go ahead nurse, that’s fine.” Nurse says ” I am not allowed to do that doctor, you need to change the order in the computer”. So now instead of reviewing the patient’s H & P, progress notes, consultant notes, labs, etc. I am busy changing the tylenol suppository to tabs. I used to just tell the RN , ” That’s fine, go ahead and change it”. Now in the guise of ” patient safety” I have to bang on the keyboard. Now, what was I doing? Oh well, it will come back to me, maybe.